Weekly docetaxel as second-line therapy for patients with advanced breast cancer resistant to previous anthracycline treatment

A dose-escalation study of SAR3419, an anti-CD19 antibody maytansinoid conjugate, administered by intravenous infusion once weekly in patients with relapsed/refractory B-cell non-Hodgkin lymphoma

PURPOSE

To determine recommended dose, dose-limiting toxicity, safety profile, pharmacokinetics, preliminary antitumor activity, and exploratory pharmacodynamics of SAR3419, an antibody-drug conjugate targeting CD19, administered alone by intravenous infusion weekly (qw), in a dose-escalation phase I study in patients with refractory/relapsed (R/R) non-Hodgkin lymphoma (NHL).

EXPERIMENTAL DESIGN

Patients with R/R CD19(+) B-NHL were treated with escalating doses of SAR3419 repeated qw for eight to 12 doses. On the basis of clinical evidence of late or cumulative toxicities, the study protocol was amended to test an "optimized" administration schedule consisting of four qw doses followed by four biweekly (q2w) doses (qw/q2w) at the recommended dose with the intent of reducing drug accumulation.

RESULTS

Forty-four patients were treated on seven dose levels ranging from 5 to 70 mg/m(2). SAR3419 recommended dose was determined as 55 mg/m(2) qw. Twenty-five patients received the qw/q2w schedule at 55 mg/m(2), which showed an improved safety profile compared with the qw schedule. Antilymphoma activity was observed with both schedules in around 30% of patients with either indolent or aggressive diseases. SAR3419 displayed a long terminal half-life (approximately 7 days) and a low clearance (approximately 0.6 L/d), with no dose effect. The qw/q2w schedule allowed limiting accumulation with a decrease in SAR3419 plasma trough and average concentrations by around 1.4-fold compared with the qw schedule.

CONCLUSION

While administered weekly, SAR3419 is well tolerated and active. The qw/q2w schedule that shows an improved safety profile and preserves antilymphoma activity is selected for clinical phase II studies.

Weekly docetaxel in the treatment of metastatic breast cancer

Breast cancer is the most frequent tumor among women worldwide and is the second cause of cancer-related mortality in the US. Metastatic breast cancer (MBC) accounts for less than 10% of newly diagnosed breast cancer patients and about 30% of early breast cancer patients will develop recurrent, advanced, or metastatic disease. It remains an incurable illness and the primary goal of its management is palliative. Several agents are active for the first-line treatment of MBC. The taxanes, paclitaxel and docetaxel, represent the standard of care for the treatment of these patients. Among the various schedules, docetaxel can be administered weekly, achieving similar efficacy results with lower toxicity compared with conventional schedules. Weekly docetaxel (25–40 mg/m²) has been widely tested in several phase I and II studies both as a single agent and in multichemotherapy regimens, reaching overall response rates ranging from 26% and 86% or 20% and 73% with docetaxel alone or in combination, respectively, depending on doses, associations, and line of treatment. Overall, published data support the administration of weekly docetaxel for the treatment of MBC patients even if data from phase III randomized trials are still lacking.

A literature-based meta-analysis taxane-based doublet versus single-agent taxane chemotherapy in patients with advanced breast cancer

PURPOSE

Clinical trials have reported conflicting results as to whether taxane-based doublet improves outcome over single-agent taxane in patients with advanced breast cancer.

METHODS

We performed a meta-analysis comparing primary and secondary end points of taxane-based doublet with single-agent taxane chemotherapy in patients with advanced breast cancer and prior anthracycline treatment. The event-based relative risk ratio (RR) with 95% confidence intervals (95% CI) was derived, and a test of heterogeneity was applied.

RESULTS

Four eligible trials (2,343 patients) were selected from 488 studies that initially were identified. A significant difference in favoring taxane-based doublet over single-agent taxane was observed in progression-free survival (PFS) (RR, 1.33; 95% CI, 1.02-1.75; P = 0.039) and partial response (PR) (RR, 1.43; 95% CI, 1.10-1.86; P = 0.008). The ORR was higher for patients receiving taxane-based doublet, although not statistically significant (RR, 1.17; 95% CI, 0.91-1.50; P = 0.220). Whereas there was no difference in 1-year survival rate (1-year SR) (RR, 1.05; 95% CI, 0.94-1.17; P = 0.422), clinical benefit (CB) (RR, 1.02; 95% CI, 0.95-1.09; P = 0.642), and complete response (CR) (RR, 0.75; 95% CI, 0.31-1.79; P = 0.512). Toxicities did not differ significantly except stomatitis and diarrhea.

CONCLUSION

Taxane-based doublet appeared to improve PFS and PR compared with single-agent taxane in the treatment of patients with advanced breast cancer. Further prospective, randomized, controlled trials will be necessary.

Metastatic breast cancer: the treatment challenge

As therapeutic options have multiplied, chemotherapy for metastatic breast cancer (MBC) has become increasingly complex. Furthermore, advances in the treatment of early-stage breast cancer, in particular the development of taxane-based regimens, have led to increased use of adjuvant chemotherapy. As a result, the decisions regarding the treatment of patients presenting with MBC have become more difficult, because many patients are likely to have received a variety of adjuvant chemotherapy regimens. The primary goal of treatment for MBC is palliation of disease--usually with prolongation of survival--with minimal toxicity. However, there is currently no "gold standard" in this setting, and the literature supports many choices for first- and second-line treatment. Other issues as yet unsettled in these patients are (1) whether to combine >or= 2 drugs or to use each drug alone until disease progression; (2) how to use novel targeted biologic agents; and (3) how to treat patients with HER2-overexpressing tumors after adjuvant treatment with trastuzumab. The role of taxanes, antimetabolites, and targeted agents in patients with MBC will be discussed in this review, particularly in the context of previous adjuvant therapy. The controversy surrounding the use of doublet or sequential therapy will also be discussed. Although considerable advances have been made toward answering these questions, many additional uncertainties have arisen, and further well-designed randomized studies are needed.

Improvement of Safety Profile of Docetaxel by Weekly Administration in Patients with Metastatic Breast Cancer

BACKGROUND

This is a retrospective cohort study on the safety and efficacy profiles of weekly docetaxel at varying doses in patients with pretreated metastatic breast cancer.

PATIENTS AND METHODS

Twenty-five anthracycline-pretreated patients received docetaxel administered on a weekly basis, as a one-hour infusion, at various dosage levels (25, 30, 35, 40 mg/m2) depending on their baseline Karnofsky index. Each 8-week cycle consisted of 6 weeks of drug infusion, followed by a 2-week rest period.

RESULTS

Of the 25 patients investigated, none achieved complete response (CR), while 9 patients showed partial response (PR), which corresponds to an overall response rate of 36%. Five patients (20%) maintained stable disease (SD), whereas 11 patients (44%) suffered tumor progression (PD) during treatment. Clinical response (defined as PR+SD) was achieved in 14 patients (56%). Median time to progression was 231 days (95% CI, 187-275). The baseline Karnofsky index was 87% +/- 9% (range: 70-100). Patients pretreated with anthracyclines only tended to have a better response than anthracycline/paclitaxel-pretreated patients (n = 6, p = 0.054). Higher dosages were associated with neurotoxicity, skin/nail toxicity, leukopenia, nausea/vomiting, fatigue/asthenia, peripheral edema, but not with diarrhea and alopecia. The cumulative dose per patient was largest for a weekly docetaxel dosage of 35 mg/m2 and almost as large for 30 mg/m2.

CONCLUSION

Balancing toxicity vs. efficacy/cumulative dosage delivered, our results support weekly administration of docetaxel at dosages of 30-35 mg/m2 in metastatic breast cancer. Response in patients pretreated with anthracyclines and taxanes may be poorer than in those pretreated with anthracyclines only.

Docetaxel-associated epiphora

Docetaxel is a semisynthetic taxane indicated for the treatment of advanced breast, prostate, and non-small cell lung cancers; it is also used for the treatment of various other solid tumors. The standard intermittent dosage of docetaxel is 60-100 mg/m2 every 3 weeks. At this dose and schedule, myelosuppression is common and neutropenia is usually the dose-limiting toxicity. Weekly administration of docetaxel 20-42 mg/m2 is being tested in the treatment of advanced solid tumors in order to improve patient tolerance by reducing the interval dose and to maintain therapeutic efficacy by increasing overall dose intensity. Asthenia and peripheral neuropathy can limit continued administration of weekly docetaxel. Epiphora (excess tearing due to narrowing or blockage of the lacrimal outflow passages) is associated with repeated weekly administration of docetaxel. This adverse effect can interfere with activities of daily life and negatively affect quality of life. Epiphora may be an underreported adverse effect of treatment because of underrecognition by clinicians and patient embarrassment with respect to seemingly uncontrolled tearing. The use of weekly docetaxel administration is expanding; therefore, patients should be educated to recognize and report signs and symptoms of epiphora. It is important for clinicians participating in the care of patients undergoing treatment with docetaxel to monitor for excess tearing and signs of eye irritation to ensure timely management of treatment-related epiphora.

Pegylated liposomal doxorubicin in combination with vinorelbine as salvage treatment in pretreated patients with advanced breast cancer: a multicentre phase II study

PURPOSE

To investigate the activity and tolerance of pegylated liposomal doxorubicin in combination with vinorelbine in pretreated patients with metastatic breast cancer.

PATIENTS AND TREATMENT

Thirty-six women with metastatic breast cancer were enrolled. The median age was 64 years, 80% of the patients had a performance status of 0-1, 30 (83%) had visceral disease and 83% had received prior taxanes while 50% anthracyclines. Treatment consisted of pegylated liposomal doxorubicin (40 mg/m2 on day 1) and vinorelbine (25 mg/m2 on days 1 and 15) every 4 weeks.

RESULTS

In an intention-to-treat analysis 2 (6%) complete and 12 (33%) partial responses were observed (overall response rate 39%; 95% CI: 23-54.8%); 8 (22%) and 14 (39%) patients experienced stable and progressive disease, respectively. The median TTP was 6.5 months and the median survival time 14.2 months. The 1-year survival rate was 54.1%. Grade 3 and 4 neutropenia occurred in 21 (58%) patients, grade 3-4 anemia in four (11%) and grade 4 thrombocytopenia in one (3%). Two (6%) patients developed febrile neutropenia. Non-hematologic toxicity was mild and easily manageable. There was no clinically important cardiac toxicity or treatment-related deaths.

CONCLUSIONS

The combination of pegylated liposomal doxorubicin and vinorelbine is an active and well tolerated salvage regimen in patients with metastatic breast cancer which merits further evaluation.

A phase II study of weekly docetaxel in patients with anthracycline pretreated metastatic breast cancer

BACKGROUND

Docetaxel has significant activity in metastatic breast cancer and weekly schedules are associated with less myelosuppression than 3-weekly schedules. We evaluated the toxicity and the activity of weekly docetaxel in anthracycline-pretreated patients.

PATIENTS AND METHODS

A total of 42 patients were studied. Treatment consisted of docetaxel 35 mg/m2 weekly as a 30-min infusion for 6 weeks followed by a 2-week rest, with dexamethasone 8 mg i.v. pre-medication and 4 mg orally 12-hourly for 48 h following treatment.

RESULTS

The median age of the patients was 53 years (range 34-74). Twenty-six (62%) patients had received prior chemotherapy for advanced disease. Patients received a median 10 weeks of treatment (range 1-24). 11 had a partial response (ORR 26%; 95% CI 13-39%), five of whom had relapsed <12 months since the end of previous anthracycline-based chemotherapy. In addition six patients (14%) had stable disease for >16 weeks. Myelosuppression was rare with only 2 patients (5%) experiencing grade 3 neutropenia (no grade 4 neutropenia). Non-haematological grade III toxicities were as follows: fatigue 17%, neuropathy 0%, hyperlacrimation 5%, stomatitis 7%, diarrhoea 14%, and cutaneous toxicity 19%. Skin toxicity consisted of limb/palmar-plantar erythematous reactions, or fixed-plaque erythrodysaesthesia.

CONCLUSIONS

Weekly docetaxel has moderate activity in women with anthracycline pre-treated breast cancer. Although the level of myelosuppression is lower than 3-weekly regimens, this weekly regimen cannot be recommended due to the significant non-haematological toxicities associated with the treatment.

Docetaxel: a review of its use in metastatic breast cancer

Docetaxel (Taxotere), a cytotoxic taxane, is an antimicrotubule agent effective in the treatment of patients with breast cancer. The clinical profile of docetaxel as an effective cytotoxic agent in the treatment of metastatic breast cancer is well established. As yet, no single standard regimen has been identified as optimal for the treatment of patients with metastatic breast cancer after failure of prior chemotherapy. However, the efficacy of docetaxel monotherapy administered every 3 weeks as a 1-hour infusion is similar to or better than that of doxorubicin, paclitaxel and fluorouracil plus vinorelbine, and better than that of methotrexate plus fluorouracil or mitomycin plus vinblastine. Although docetaxel is associated with neutropenia and other adverse events, its overall tolerability profile is generally acceptable in the majority of patients. Docetaxel, therefore, is an effective option in the treatment of patients with metastatic breast cancer after failure of prior chemotherapy.

Weekly administration of docetaxel and paclitaxel in metastatic or advanced breast cancer

The taxanes docetaxel (Taxotere; Aventis Pharmaceuticals Inc., Bridgewater, NJ, http://www.aventispharma-us.com) and paclitaxel (Taxol; Bristol-Myers Squibb, Princeton, NJ, http://www.bms.com) have significant clinical activity in metastatic breast cancer. A number of clinical trials have evaluated the tolerability and efficacy of weekly taxane administration to optimize the benefit-to-risk ratio in metastatic breast cancer. Single-agent studies with docetaxel and paclitaxel in metastatic breast cancer show clinically significant antitumor activity even in advanced, heavily pretreated, resistant, and/or refractory disease. This activity is also evident with taxane-based combination regimens. Severe hematologic and nonhematologic toxicities are infrequent, with other toxicities noted based on the dose and weekly regimen selected. Weekly docetaxel and paclitaxel regimens represent valuable therapeutic options for women with metastatic breast cancer and have entered evaluation as part of adjuvant therapy for this disease.

Cyclophosphamide-methotrexate 'metronomic' chemotherapy for the palliative treatment of metastatic breast cancer. A comparative pharmacoeconomic evaluation

BACKGROUND

Metronomic chemotherapy-the chronic administration of chemotherapy at relatively low, minimally toxic doses on a frequent schedule of administration at close regular intervals, with no prolonged drug-free breaks-is a potentially novel approach to the control of advanced cancer disease. It is thought to work primarily through antiangiogenic mechanisms and has, as an advantage, the property of significantly reducing undesirable toxic side-effects. The aim of the present study was to evaluate the cost effectiveness of cyclophosphamide-methotrexate 'metronomic' chemotherapy in the palliative treatment of pretreated metastatic breast cancer.

METHODS

Low-dose cyclophosphamide-methotrexate 'metronomic' chemotherapy was compared with outcome and resource utilisation data of published phase II trials regarding metastatic breast cancer, performed in western countries, mostly in Europe. All direct costs associated with metastatic breast cancer treatment were included and adjusted to year 2003 values. Sensitivity analyses were performed and variations to the values of key parameters were assessed.

RESULTS

Low-dose cyclophosphamide-methotrexate 'metronomic' therapy was assessed to be a cost-effective/cost-saving therapy for palliative treatment for metastatic breast cancer when compared with novel chemotherapy strategies (phase II trials). Compared with the 11 phase II mono- and combination chemotherapies, metronomic treatment showed marked cost savings in each case and improved cost effectiveness. Sensitivity analyses showed the results were robust to variations to the values of key parameters with very few exceptions.

CONCLUSIONS

Metronomic cyclophosphamide-methotrexate is significantly cost effective. If validated by prospective randomized trials, the treatment concept could reduce healthcare costs, especially those associated with the combined use of new, highly expensive, molecularly targeted therapies.